Photo Medley

The three on the left are short term doctors, the two in the middle live here and you know the shady looking character on the right.












My fellow workers on the medical ward.















Jack and Will are back at paper modeling.

The view from the beach (our friends' roof)

Braille

Doing the dishes by braille

In Dhaka the power would go irregularly (often with the distant 'kaboom' of an overloaded exploding transformer) -it varied, but seemed to go in fits and spurts; sometimes a month would go by without an outage.

Here in Parbatipur it's a daily occurrence - actually multiple times each day.  The hospital has 3 large diesel generators that start automatically.  However, they take a few minutes to spool up so when the power goes, it's about 3 minutes before it comes back on.  We try to take it stride.

Actually, we try really hard to take it in stride.  Especially when around other people.  If the power goes in the middle of a sentence, or in the middle of raising a bite of food to my mouth, and despite the internal 'jump' I feel, there's no outward sign....if the sentence finishes without a hiccup, or if the bite travels to mouth without the slightest pause, then inside I go, "Woohoo!  I'm so cool!  I totally look like I'm an old hand at this stuff!  I'm so hip I don't even flinch when the power goes out! Yeah!".

Yes, I really am that grown-up.

Unstable SVT

Medical post

It's been a quiet call night - my junior doctor (S) did not call until 5am.

A young man (30 yrs) came with 7 1/2 hrs of chest pain and shortness of breath.  S described the ECG; clearly he was concerned about a heart attack but felt like he was missing something.  His instincts were right: although there were some signs of 'ischemia', or reduced blood flow, on the ECG, the primary issue was an arrhythmia - the heart was beating far too fast.  This was not a clogged artery, but rather a heart that didn't have enough time between beats to get blood flow.  The solution was to try and stop this arrhythmia (a Supra-Ventricular Tachycardia or SVT).

You may be able to see the ECG tracing on the screen of the defibrillator

We tried several maneuvers to 'break' the SVT (culminating in dunking this dignified young man's head in ice water) but ultimately had to do synchronized defibrillation.  We gave him some intravenous valium (so he wouldn't remember) and I handed the paddles to S.  Everyone cleared back from the metal bed frame, S leaned in (looking a bit nervous), pushed the buttons, and.....THUB....for a very long 1 1/2 seconds there was nothing at all.  I think S's heart may have stopped of the same length of time.  Then the heart restarted, in normal rhythm, and the patient's chest pain rapidly receded.

When our hearts don't respond to the usual maneuvers, sometimes they need a shock.

Moo

How are these two pictures related?

A convenient place to dry cooking fuel.

Neurosurgery

Tonight I was called upon to try my hand at neurosurgery for the first time.

Initially it looked bad.  The patient was unresponsive after a serious head injury.

Fortunately, after a highly technical operation of 'stuffing-stuff-back-where-the-stuff-belongs' I was able to complete primary closure with  reasonable cosmetic outcome.

Zebra Crossing

This is a familiar item.  In the US it's a crosswalk, in the UK, a Zebra Crossing (for the stripes).  Of course, here it's funny because it's not even a suggestion of where to cross - nobody knows what it's for.  You cross wherever, just like cars and trucks drive wherever.

W mentioned yesterday that he was thinking of when we'd be back driving in the States, about how we'd be on the, "Right side, I mean, correct side of the road."  which occasioned gentle remonstrance.    While there are things that happen elsewhere that are genuinely wrong, most things that we think are, "Wrong, Unnatural, and Bad." are really just, "Different."  It honestly doesn't matter which side of of the road you drive on, and there really are good reasons why even the left side is just a suggestion.

Many times, if you catch yourself thinking, "That's Wrong, Unnatural and Bad." do a quick double take and you may find it's just "different".  Newlyweds often encounter this!  Two people, from different 'cultures' (families) always have different ways of doing things:

"Don't load the dishwasher that way!"

"Why?"

"It's the wrong way!  They fit more naturally this way."

"But that's not the right way to do it!"

"Yes it is!"

It is very important, of course, to recognize that not everything falls into the 'different' category.  Some things genuinely are wrong.  But you'd surprised how much what we take for granted as, "The right way...." is just "Our way".

One Word

Lice.

Breezy

If by some chance you put it a request at the weather bureau for cooler weather for us, thank you!  The last three days have been delightful, at least up here in Parbatipur.  I was worried about the folks in Cox's Bazar (where cyclone Komen made landfall) but a friend down there assured me it's not bad.
So we've had relatively cool weather and a breeze for several days - it's beautiful.

Declaration

Something occurred the night before last.   I hesitate, but feel compelled to write.  It'll be necessary that I relate this in as detached a way as possible; you'll understand why.  I've never written about something like this before and what I write might disturb some.
As a preamble: I know death - I have seen many, many people die over the last 18 years and it happens quite a bit here.  My job is trying to help them dodge it for a while, but that is frequently not possible.


I spent most of Thursday night at the bedside of an older woman in cardiogenic shock - life threatening low blood pressure from a very large heart attack.  I'm happy to say she survived the night and was improving by the morning (an RVMI, for you medical types).

While I was caring for her, one of the nurses ran in, rattled off something in high-speed Bangla and ran out.  I didn't catch it, but it was easy to hear the urgency.  I followed him to the bedside of a young man, NZ, who was in septic shock on pressors (continuous infusion of medicine to raise the blood pressure - a form of life support).

NZ was in agonal respirations.  Agonal respirations are the last few, slowing, reflexive breaths of a body in which the heart has previously stopped pumping.  They are unmistakeable; the duration varies, but I often note them for a couple of minutes after asystole begins (circulatory death).

He was already on the maximal treatment we could provide (we don't have a ventilator available at this time), so given our very limited abilities and his desperate illness, I had concluded earlier that, should he deteriorate, CPR and 'heroic measures' would be futile.  I stood watching at him for a moment, then leaned in to check for a carotid pulse, listen to his chest, and complete my job.  There were no heart sounds and there was no pulse.  I reported to the staff that he had died and I looked at my phone so I could officially declare the time of death.

As I looked down I saw the nurse who had called me, praying.  As I looked up I saw the patient take in an entirely different kind of breath.  I quickly reached out and rechecked the carotid - there was a pulse where there had been none.  His respirations began rapidly changing in character.  I listened for heart sounds then grabbed a blood pressure cuff - 60/30.  I looked up in consternation, looked back down and rechecked - now 110/60.  After some minutes, he opened his eyes and asked for some water.


Please don't comments on this post: I need a little time to just think about it.